Medical and Dental Medication Form | Shelby County Veterans Court

Medical Facility / Clinic *

Physician'S Name

Street Address

City

State

Telephone Number

Fax Number

This Notification Is To Inform You That

Name Of Shelby County Veterans Participant

Is currently a Shelby County Veterans Court participant and is a recovering addict / alcoholic. As part of a structured, judicially supervised treatment program, the Veterans Court participants are frequently subjected to random drug testing. Therefore, all medications and treatment procedures should be prescribed with this information in mind.

Diagnosis / Treatment

Prescription

Please Specify Medication Type And Dosage

"The Small Expense Of Restoring An Individual To Health And Usefulness Is Returned Manifold."
--- Dr. Charles H. Mayo